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MI M M M-dr- END- <br /> Chain-of Custody Number <br /> SECQR. Chain-of Custody Record <br /> Field Office <br /> ' ,d W,Additional documents are attached, and are a part of this Record <br /> Address 4 IP-1 ;Y gsvaP 0"2-69 Job Name <br /> Location <br /> Project # SU 3 ^DZTask # Analysis Request <br /> Project Manaer_?- rF,' <br /> Laboratory <br /> Turnaround Time IL w z 0ca <br /> N V C <br /> 41 U j O6 CO 0 <br /> y C <br /> X� o �C3 �C7 a ? y U <br /> Sampler's Blame � +Y ►.. J o a o CO U O 0 a �o �o a)o � Q r <br /> Sampler's Signature � -- o o) E Q °'a m ° CO N v <br /> _`^ "X Lo T o c� 5 c o2 E in y 3 acv o` COmrnerlfS/ <br /> Sample ID Date Time Matrix CO ti o ¢n n z o U) a� 1" a`� Instructions z <br /> j .", `� �' !•2-Y ` � - 9 � <br /> 'S <br /> r L/ <br /> Special Instructions/Comments Relinquishe by Received by - Sample Receipt <br /> } Sign ign Total no of containers <br /> Print a Print Chain of custody seals <br /> ll! Company 5 Com Recd in good condition/cold <br /> V ��I*v�� Time ��` Date —Z 6 e Q e Conforms to record <br /> cis Relinquished by Rl~ceiv by <br /> Sign _ Sign Client <br /> Print Print SW Client Contact <br /> Cm an Com anY <br /> TiDate Time _ Date.V- Client Phone <br /> SECOR CUSTREC Rev 1/95 g/ <br /> ' Date .- 1 126 I (� Page-7-- of <br />